Provider Demographics
NPI:1831846005
Name:WILSON, QUINN D (MS)
Entity type:Individual
Prefix:
First Name:QUINN
Middle Name:D
Last Name:WILSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4570 WILSON AVE APT A
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-5529
Mailing Address - Country:US
Mailing Address - Phone:619-270-6949
Mailing Address - Fax:
Practice Address - Street 1:1223 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3301
Practice Address - Country:US
Practice Address - Phone:425-296-9793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT123526106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist